Policy Papers

Health and Wealth

Simon Szreter | 07 November 2005

Executive Summary

Hindsight: contemporary international policies to promote economic growth and development are too often premised on a view of the past distorted by hindsight and unwitting present-centredness.

Disruption: history teaches that economic growth is a profoundly disruptive and uncertain process, particularly with respect to population health.

Information: essential public-health intelligence and even the registration of individual identities is lacking in many poor countries today, unlike in the European past.

Social security: a system is lacking in most poor countries, yet the English Poor Law was crucial in facilitating development in the world's first industrial nation.

Democracy: the relationship between democratisation and development is not straightforward. Healthy democracies need representative, independent local government, balanced by national, central government, not just votes for all.

Social capital: the diverse and changing structures of relationships of trust and respect in society have great influence over all forms of policy implementation.

Time: history teaches respect for thinking with appropriate units of time. Development processes occur in generations- quarter and half centuries- not annual accounting units or 5-year electoral cycles.

History and Policy: the historicist perspective

As its title indicates Health and Wealth. Studies in History and Policy (H&W) is a volume of essays intended to exemplify the purpose of the History and Policy website and the new History and Policy unit established at the Centre for Contemporary British History. H&W demonstrates how history can be deployed extensively to re-think major topics in the social and policy sciences concerning economic change and health.

The chapters of H&W present a series of revisionist historical articles published since 1988 on mortality change in Britain during the last three centuries. These chapters challenge orthodox and conventional social and policy-science views of the processes that govern the relationship between modern economic change and population health. By providing distinctive historicist perspectives, they also suggest a number of positive alternatives for contemporary development and public-health policies, which will be summarised here.

The historicist perspective in H&W seeks to avoid the fore-shortening and 'straightening-out' of time through the distorting lens of hindsight. This is one of the characteristic flaws of the contemporary social sciences in their attitude towards the past. History is too frequently seen merely as the sign-posted path to the present, as if everybody in the past (or the most important and progressive elements) somehow knew that they were headed towards the society and economy which we currently inhabit. According to this viewpoint, the only real question is how long did they take to get here? How fast was the rate of economic growth in different periods and what interfered with it or promoted it? When did our society pass through the different stages of the demographic transition to arrive in modernity? The first and cardinal point to emerge from adopting an historicist perspective is to recover the prospective indeterminacy of the past.

The people who populated the past did not know where they were going, just as we cannot predict with any confidence at all what kind of society or economy our grandchildren will inhabit in a hundred years' time. Like us, people in the past had dreams and ideals, fears and aspirations, but they certainly were not the same as ours and they were mostly to do with the next year, five years or ten years ahead of them.

Economic change, disruption and uncertainty

Most of the articles in Health and Wealth explore the history of demographic change in Britain during and after the industrial revolution, c. 1750-1914. The first insight to emerge from adopting an historicist perspective is that the economic growth occurring in Britain during this period was intensively and extensively disruptive. It is argued in H&W that this is an important general characteristic of 'successful' national economic growth almost everywhere that it occurs. Societies, governments and international NGOs working today to promote economic growth in the world's many poorer countries frequently fail to appreciate that the very goal which they are striving to bring about, and which would count for them as an index of their success- consistently rising rates of growth of national income- will bring with it a wide range of profoundly de-stabilising forces. It is not just absence of economic growth that can be a problem: its presence will also cause numerous difficulties, though they will be different ones.

Widespread poverty, lack of opportunity for whole sections of society such as women and children, and the pain and loss of emigration may characterise life in societies lacking economic growth. However, the first and greatest economic 'success' story of all, the industrial revolution in Britain, also shows that the achievement of economic growth in such societies will exacerbate migration rates from some regions still further; cause local or even regional-scale environmental hazards, such as water shortages, occupational diseases and air pollution; and will divide communities, families, and generations as relative values of assets are altered and some adopt new ideals and models of behaviour, while others cleave to established norms. Changing economic fortunes for some will also produce intense political uncertainty and turmoil in a social landscape where there are frequently as many who perceive themselves to be directly disadvantaged and their conditions of life threatened by economic change.

The counsel of history is not, however, the Luddite one of rejecting the goal of economic growth as not worth the trouble. Human aspirations to escape material poverty and to pursue self-fulfilment are valid and, apart from ascetics, universal; they both entail the desirability of economic growth. The purpose and value of arming oneself with a thoroughly historicist understanding of the difficulties involved in taking this crooked path is precisely to make it possible to negotiate effectively the bewildering and un-signposted road ahead, fore-warned with a more realistic set of general expectations about the chaos and disruptions that must be faced.

The orthodox social-science and development models tend not to portray such a picture of an intrinsically disruptive process. This is for the simple reason that they are not constructed to do so. Part One of H&W deploys the methods of historical enquiry to show how some of the most influential social-science models in the post-war era, such as the theory of demographic transition and the 'Mckeown' thesis of nutritional improvements driving mortality decline, were developed and deployed to provide reasoned support for selective policy goals. They were constructed teleologically as guides to positive action in the present and the future, utilising selective accounts of historical change to show that history had apparently moved in the manner, which, they were advocating, should now be followed.

A genuinely historicist account does not portray such perfectly accomplished teleology. Historical research more typically uncovers false starts, paths taken then abandoned, unintended consequences, conflicts, uncertainties and plain old-fashioned mistakes. However, the fact that the historical path is so crooked and pot-holed that nobody in their right mind would want directly to attempt to emulate it does not mean that there can be no helpful advice to be gleaned from the study of history. Indeed, it is in order not to repeat in ignorance all the follies of the past that one can usefully study history. For instance, one such helpful piece of historicist advice is to be prepared for a rough and dangerous ride in a society embarked on the experience of rapid economic growth, especially if this is for the first time in its history. A second general piece of advice is that the civic and political institutions a country possesses at the outset will be extremely important in influencing just how rough the ride can get; and they will have to adapt to change more rapidly than can often be easily achieved.

Both these pieces of historicist advice have very direct, practical policy implications, namely that just as much attention needs to be paid by those in government or by international NGOs to the form, vigour and adaptability of crucial civic and political institutions, as to the openness of the economy and its financial institutions or to the state of schools, roads and hospitals. They should be prepared in advance to cope with the eventuality that rising per capita national income will very probably be accompanied by social disruptions and health problems, so as not to be disagreeably taken by surprise once economic 'success' begins to exert these influences.

The chapters in Part Two of H&W investigate how and where such disruptive problems were precisely manifest in British history. It finds that among the English population there were grossly adverse health and mortality consequences of rapid economic growth. These were in fact concentrated among the urban proletariat in precisely the same locations where the new industrial wealth was being generated, the factory cities. Immigrants from both the rural hinterland and from Ireland (even before the famine added extra impetus) came to find work and higher wage rates; but equally frequently they and their wives and children also found higher death rates.

The importance of public-health information: vital statistics

Unlike many of the poorest nations in the world today, the English, by the beginning of the 1840s, did at least possess a sophisticated public-health intelligence system and these high urban death rates were increasingly analysed and denounced as 'preventable' by the government's own officials. One of the many important, albeit conditional, lessons of British history in the nineteenth century is that authoritative, universal and high quality public-health information is a necessary- but, alas, not sufficient- item of institutional machinery, which societies require in order to be able to address the epidemiological problems which economic growth, trade and increasing density of urban settlement inevitably produce. A comprehensive public-health information system is not a high priority among many of today's least developed nations and it is a great disadvantage which they labour under, neither knowing where and whom their worst health problems afflict, nor whether any remedial measures are truly taking effect.

H&W is able to show that, through the effective public-health propaganda machine of the General Register Office, the Victorian urban, middle and upper classes were never under any illusions as to the unhealthy state of their towns, even during the periods of relative respite between cholera visitations. By the 1830s and 1840s mortality was probably higher in most industrial towns than it had been at any point in the previous 100 years of their development. Since we can be sure that the Victorians were not simply ignorant of their predicament, this helps to identify other factors which prevented them from acting on this knowledge. It was not all towns, but especially those where the new industrial and commercial wealth was being made, which were especially unhealthy. Furthermore, health in such towns distinctly deteriorated in the 1830s and 1840s as diseases such as smallpox, almost eliminated two decades previously by vaccination, returned; and others, such as cholera, struck for the first time.

'Democratisation': not a simple panacea

The thesis developed in Part Two of Health and Wealth is that all manufacturing cities, such as Glasgow, Manchester and Liverpool, but also smaller ones such as Carlisle, Warrington or West Bromwich, became politically and administratively hamstrung for over half a century from the end of the Napoleonic Wars. This happened because of the unintended consequences of partial, 'democratic' reform of the polity. In common with the 1832 'Great' parliamentary Reform Act, the 1835 Municipal Reform Act gave votes to moderate property holders. Town government passed out of the hands of a narrow wealthy oligarchy and into those of a 'shopocracy' of petty bourgeois ratepayers. The highly restricted borrowing powers of urban corporations were already the source of serious problems, preventing these fast-growing towns from undertaking costly sanitary and environmental infrastructure projects: resulting, for instance, in the water supplies often being sold to private companies in the forlorn hope that they would make improvements to capacity, which the town's authorities were statutorily unable to undertake. For a whole further generation after 1835, while Britain's industrial towns expanded into crowded cities, their petty capitalist ratepayers refused to vote for anything except policies of do-nothing 'economy'.

Central government tried to force their hands with the 1848 Public Health Act but this was largely rebuffed. Borrowing and expenditure statistics clearly show that British cities did not really begin to invest in the expensive sanitary works which the 1848 Act hoped to encourage until the 1870s, when their electorates began to express support for such measures. This did not happen until after the municipal electorates were substantially extended in 1869. At that point a new generation of urban neo-patricians, led by the industrial magnate Joseph Chamberlain in Birmingham, realised that it was now possible to appeal with a municipal spending programme over the heads of the petty bourgeois to the non-rate-paying but voting working class. The largest employers and their workers both stood to benefit substantially from collective expenditure on the urban environment, which would boost the health and productivity of the workforces, while the petty bourgeoisie were now, finally, co-opted into helping to pay for it.

Although the exact course of historical events summarised here is specific to Britain in the nineteenth century and will never be precisely repeated again anywhere else, this does not mean there are not any generalisable policy lessons that can be drawn. In fact it is only by paying careful attention to this genuinely historicist version of British economic and demographic history- the crooked path of pitfalls, false turns and grubby local politics- that policy makers can learn anything they do not already know. The smoothly-surfaced high-road of models of historical change based on inspecting secular trends in national economic growth rates and aggregate demographic indices is, after all, merely a historical mirror reflecting back our own contemporary goals, wishes and assumptions.

There are, then, a number of specific but generalisable lessons about the relationship between economic change and population health, which can be gleaned from the historicist perspective on nineteenth-century British history, and these are elaborated in Part Three of H&W. These 'lessons' could be applied to societies undergoing rapid economic growth for the first time under political regimes that are at least moderately liberal and partially 'democratic', which probably covers most poor countries today, excluding those which are effectively one-party states or subject to dictatorial rule.

Firstly, the analysis in H&W demonstrates that the expansion of democracy per se under conditions of economic growth has no necessary beneficial health effects. Increasing degrees of 'democratisation' can have entirely diverse consequences. Careful attention must be paid to issues of representation, to the local details of franchise extensions and to the precise political means available for the opinion of the poor to be influenced and expressed (issues of public information media and party organisation). The interests of those who are given voting power and how this relates to those other sections of the population (children for instance in today's poor countries) who remain excluded cannot be ignored. Given the unavoidably expensive nature of maintaining- let alone improving- population health under the conditions of the large-scale urbanisation and migration which invariably accompany rapid economic growth, this can determine whether or not the political conditions exist at all for the required collective action to implement health-preserving technologies. In Britain the wrong kind of 'democratisation' of the national and urban electorates produced unbreakable political stalemate for a generation after the 1830s, while urban environments deteriorated and public health suffered.

Central and local government: a delicate balancing act

Secondly, H&W indicates that the exact relationship between central and local government may well be a crucial one. Imbalances of power in either direction may be counter-productive. Too much power and talent at the centre, as in Britain in the 1830s and 1840s, may result in a counter-productive, one-size-fits-all dictatorial style, undermining the vigour of provincial governments and only eliciting evasion or even rejection in the provinces of initiatives from the centre. Local representative and elected governments which are endowed with genuine independence, powers, status and resources, will very likely generate a competitive political forum across the nation of (literally) healthy rivalry among them. The centre may well be able to foster such productive competitiveness through a judicious policy of both financial and honorific carrots and sticks.

Relations between centre and periphery are probably optimal when characterised by a diplomatic and mutually respectful relationship based on genuine relative autonomy, rather than by relations of dependence (or complete independence), with the centre both prepared to learn from provincial innovations taken by energetic local authorities and to encourage and incentivise the spread of best practice where initiative is lacking. This characterised relations between central and local government in Britain over matters of health policy during the era of the Local Government Board, 1870-1919, when much was achieved in the improvement of the urban population's health.

The importance of public servants, professionalism and social capital

Thirdly, the effective delivery of health-preserving and enhancing services under the challenging conditions of rapid economic growth will require motivated bodies of trained and committed personnel at ground level. In British history this took the form of a combination of an expansion in long-standing religiously-motivated voluntary philanthropic organisations and the new growth of 'public service professions'. The latter were mainly employees of elected local governments, possessing specialist knowledge and training supervised by professional examining bodies (institutions licensed by the central state to exert independent and accountable control over an area of formal knowledge deemed to have direct, public importance). The generalisable point is the importance of creating a dutiful, committed, impartial and highly professional bureaucracy to serve elected local government, with rewards so scaled that professional talent does not leach away from the provinces to the centre.

Fourthly, H&W points to the manifold importance of 'social capital'. Social capital refers to the patterned structure of relationships which, often invisibly, criss-cross and structure society through the operation of networks and their associated norms. Social capital is a more general concept than 'civil society' because in principle it embraces all forms of networks, formal and informal, including nepotistic and 'hidden' ones - those which do not necessarily benefit the wider collectivity - as well as those which are more open, such as the many voluntary societies which exist to pursue harmless leisure activities or laudable, public aims. Social capital was significant in throwing up barriers to collective action by contributing to the mutually distrustful fissuring of British urban communities under the severe pressures of rapid growth during the first half of the nineteenth century. But social capital was also important in the changed context of the late 1860s and 1870s in enabling collective municipal action, providing both Chamberlain personally and the local Liberal party in the city of Birmingham with diverse means of communication and mobilisation to achieve electoral support for a new municipal politics of urban improvement and spending.

Social capital is also important in another way, in relation to the manner in which public-health and social services are delivered. Such services typically require extensive interaction between service providers and clients. Physical capital, facilities and medical science are of course also all involved, but maintaining or improving the health of whole urban populations which are having to adapt to the new environmental challenges thrown up by rapid economic growth requires much face-to-face interaction, especially between the poor, the displaced and the disoriented on the one hand, and various categories of officials and trained workers such as nurses and health visitors on the other. The quality of the human relationships characterising these interactions can be critical. The concept of linking social capital discussed in H&W emphasises how important are norms of respect governing this relationship, something which can be very difficult to achieve given the imbalance of power and expertise between professional and client in these circumstances. It is too easy for the possession of superior knowledge to become a stick with which to beat the poor. The vital ethos of professionalism in the public services has to include genuine respect for those with whom it works.

Systems of social security: a neglected lesson of history

Fifthly, there is the enormous significance in all polities of social security systems. At the minimum this is provided universally by kin and neighbours. Wider resources and agencies are, however, typically also involved in most societies, such as religious, philanthropic and mutual self-help organisations. Most economic, social, medical and policy scientists and NGOs operating in the 'development' field would assume that nationally-organised, government-based, official social-security systems are historically a relatively recent addition, famously innovated by Bismarck in the new German Empire in the 1880s, developed more extensively by Denmark and Sweden in the twentieth century and achieving their most developed form as 'the welfare states' of post-war western Europe. Such comprehensive social-security systems appear in this perspective to be the final fruits of decades of economic growth; and there are many economists who have serious reservations about their consequences for the vigour of national economies- doubts which have arguably prevented the USA from following the west European lead.

However, as the final chapter of H&W argues, a more thorough knowledge of British history transforms such assumptions about the historical relationship between national social-security systems and economic growth. Britain, the world's first and only example of self-induced rapid economic growth and industrialisation, possessed a fully-functional national statutory social-security system for two centuries before the industrial revolution. The Poor Laws, enacted in the reign of Elizabeth I, endowed the country with a uniquely comprehensive social-security system. Dutch historians have identified this as having given the British agrarian economy a crucial advantage in terms of the market flexibility and mobility of the primary factors of production, land, labour and capital. This was an important contributory factor enabling the British economy in the course of the seventeenth and eighteenth centuries to overtake the leader, Holland. Paradoxically the British 'free market' economy flourished as no other at the time because of the unparalleled strength not only of the central state in providing external military security and protecting the textile industries, but also because of the generous provision of domestic social security by the local state. The neo-liberal consensus that has emanated from the world's great financial institutions in Washington and New York for the last quarter century has been entirely ignorant of these lessons of history.

Identity and registration: back to the importance of information

A sixth lesson is the importance of civic-identity registration. This, like the social-security system, was another central-government-sponsored and locally-organised foundational element in the story of precocious economic and social development in England. The flowering of a widely-spread property-owning and property-disposing agrarian and commercial middle class of improving landowners, yeoman-farmers and merchants was a major feature of British agrarian capitalism. Access to a cheap and effective system for proving legal identity was as important for the smooth working of a society used to exchanging and inheriting property as it was for the smooth operation of the social-security system. For this aspect of British history to be emulated in today's poorer countries would require a government or World Bank-funded network of trustworthy and secure civil registers, proof from the possible abuse of such information by unscrupulous commercial or official agencies. Not easy to achieve. But without this, the citizens and would-be capitalists of poor countries are alike labouring under severe burdens of basic information deficits, like their public-health systems in the absence of public-health intelligence (something which in Britain's case was generated very economically as a by-product of its civil registration system).

The last lesson of history: the importance of time

Finally, an historical approach to studying economic and demographic change emphasises the importance of time. The social and policy sciences tend to have an unrealistic, almost frenetic conception of time. Policies are expected to demonstrate effects within a year or two. Partly the result of electoral cycles in democracies, five years is today considered a maximal time horizon by most governments or NGOs- ironically the same accounting unit envisaged by the proud and impatient planners of the USSR. But, being such a disruptive and chaotic process, economic growth and its evolving relationship with the environment and with population change and public health is a large-scale process, whose consequences tend to unfold in decadal and generational, rather than annual units of time. Policies designed to work at the appropriate scale and level themselves require to be conceptualised according to such time-scales.

Furthermore, as has been illustrated by the regionally-devastating HIV-AIDs pandemic of the last quarter century, when disruptive economic change does cause things to go wrong from a health point of view, it can be on a colossal scale, both temporally and geographically, with major economic consequences. It is questionable whether the world's international development institutions or the governments of poorer countries have ever truly understood this prime lesson of history. It was a wholly realistic assessment of the national insecurities and potential costs arising from such calamities, which was a part of the rationale behind the English state launching its pioneering, comprehensive social-security system in the sixteenth century, resulting in the historical fact that England achieved freedom from any famine-induced mortality well over a century before any other part of Europe. If this had been given the highest development policy priority, which history suggests it should have had during the last half-century, who can say how different the impact and cost of AIDs would have been? Would we have seen the recurring regional famines which are a blight on our age if the world's poorest countries had been encouraged instead to build for themselves a proper social-security system before being exposed to the necessary disruptions of the global economy?

Further Reading

Simon Szreter, Health and Wealth: Studies in History and Policy, Rochester Studies in Medical History (Rochester University Press 2005).

About the author

Simon Szreter is Reader in History and Policy, Faculty of History, University of Cambridge and Fellow of St John's College. With Alastair Reid, he is a founding editor of the History and Policy website. srss@cam.ac.uk.

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